Ms A’s complaint centred on whether the care and treatment provided to her by the Health Board, and specifically its assessment and management of her risk of suicide and self-harm, on specified dates was appropriate.
The Ombudsman’s investigation found that broadly the assessment and management of Ms A’s risk of suicide was reasonable. It is recognised that in Ms A’s case, the clinical situation was complex due to a number of presenting issues, including around her self-harming. However, in the absence of evidence of a serious mental health diagnosis, the assessment of risks and benefit undertaken by the mental health services had concluded that continued inpatient admission in the mental health unit increased Ms A’s risk of self-harming. It was felt that Ms A could benefit more from community based mental health support. Ms A’s further presentations and assessments did not change this clinical view.
The Ombudsman’s investigation did identify isolated instances where documentation, for example, was not as good as it could have been. However, the Ombudsman found that this did not cause Ms A an injustice. On the evidence considered, Ms A’s complaint was not upheld.
However, as a point of learning the Health Board was asked to consider the issues identified around documentation and look at introducing a specific policy relating to patients who refuse inpatient discharge if such a policy was not already in place.